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Research ArticleOther and Special Categories

Presentation, Management, and Outcomes of Thoracic, Thoracolumbar, and Lumbar Spine Trauma in East Africa: A Cohort Study

Chibuikem A. Ikwuegbuenyi, François Waterkeyn, Arthur Okembo, Costansia Bureta, Kassim O. Kassim, Hamisi K. Shabani, Scott Zuckerman and Roger Härtl
International Journal of Spine Surgery April 2024, 18 (2) 186-198; DOI: https://doi.org/10.14444/8575
Chibuikem A. Ikwuegbuenyi
1 Department of Neurological Surgery, New York Presbyterian Hospital/Och Spine, Weill Cornell Medicine, New York, NY, USA
2 Division of Neurosurgery, Muhimbili Orthopedic and Neurosurgery Institute, Dar es Salaam, Tanzania
MD
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François Waterkeyn
3 Department of Neurosciences, Grand Hôpital de Charleroi, Charleroi, Belgium
MD
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Arthur Okembo
2 Division of Neurosurgery, Muhimbili Orthopedic and Neurosurgery Institute, Dar es Salaam, Tanzania
MD
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Costansia Bureta
2 Division of Neurosurgery, Muhimbili Orthopedic and Neurosurgery Institute, Dar es Salaam, Tanzania
MD, PHD
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Kassim O. Kassim
2 Division of Neurosurgery, Muhimbili Orthopedic and Neurosurgery Institute, Dar es Salaam, Tanzania
MD
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Hamisi K. Shabani
2 Division of Neurosurgery, Muhimbili Orthopedic and Neurosurgery Institute, Dar es Salaam, Tanzania
MD, PHD
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Scott Zuckerman
4 Departments of Neurological Surgery and Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
MD, MPH
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Roger Härtl
1 Department of Neurological Surgery, New York Presbyterian Hospital/Och Spine, Weill Cornell Medicine, New York, NY, USA
MD
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  • For correspondence: roh9005@med.cornell.edu
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  • Figure 1
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    Figure 1

    Fracture types among 257 thoracic, thoracolumbar, and lumbar spine trauma patients (each fracture type counted separately when more than 1 injury was present).

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    Figure 2

    (A–C) Axial, sagittal, and coronal preoperative computed tomography images of a patient with L1 burst fracture. (D, E) Intraoperative x-ray anteroposterior and lateral views after instrumentation.

Tables

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    Table 1

    Demographics, injury, and hospitalization information of patients with thoracic, thoracolumbar, and lumbar spine injuries.

    VariableTotal
    N = 257
    Operative
    n = 167
    Nonoperative
    n = 90
    P
    Age, mean ± SD, y35.2 ± 11.334.4 ± 11.336.8 ± 11.30.059
    Sex, male, n (%)215 (83.7)137 (82)78 (86.7)0.435
    Insurance, n (%)0.819
     Public225 (87.5)145 (86.8)80 (88.9)
     Private32 (12.5)22 (13.2)10 (11.1)
    Mechanism, n (%)0.439
     RTA112 (43.6)76 (45.5)36 (40)
     Fall95 (37.0)57 (34.1)38 (42.2)
     Other50 (19.4)34 (20.4)16 (17.8)
    Admitted to OSH, n (%)255 (99.2)166 (99.4)89 (98.9)1.000
    Location, n (%)
     Thoracic52 (20.2)34 (20.4)18 (20)1.000
     Thoracolumbar junction (T10–L2)189 (73.5)126 (75.4)63 (70)0.425
     Lumbar16 (6.2)7 (4.2)9 (10)0.116
    Imaging, n (%)
     X-ray imaging207 (80.5)131 (78.4)76 (84.4)0.320
     CT80 (31.1)55 (32.9)25 (27.8)0.477
     MRI152 (59.1)101 (60.4)51 (56.7)0.719
    Neurologic status, n (%)
     Complete (ASIA A)117 (45.5)80 (47.9)37 (41.1)0.362
     Incomplete (ASIA B–D)81 (31.5)62 (37.1)19 (21.1)0.013
     Intact (ASIA E)59 (23)25 (15.0)34 (37.8)< 0.001
    Indication for surgery, n (%)232 (90.3)167 (100)65 (72.2)< 0.001
    Length of stay, median (IQR), d25 (14–43)28 (15–45)22.5 (11.2–41.8)0.117
    Time from injury to admission, median (IQR), d3 (1–7)3 (1–6)3 (1–9.8)0.755
    Pressure ulcer, n (%)a 54 (21)32 (19.2)22 (24.4)0.419
    Mortality, n (%)3 (1.2)1 (0.6)2 (2.2)0.584
    • Abbreviations: ASIA, American Spinal Injury Association; CT, computed tomography; IQR, interquartile range; MRI, magnetic resonance imaging; OSH, outside hospital; RTA, road traffic accident.

    • ↵a One missing value.

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    Table 2

    Operative details of those undergoing surgery.

    ParameterValue (n = 167)
    Operation new, n (%)a
     Posterior fusion thoracic/lumbar163 (97.6)
     Decompression only3 (1.8)
    Screws, mean ± SD5.6 ± 1.7
    Number of levels fused, mean ± SD2.7 ± 1.1
    Postoperative imaging, n (%)
     X-ray imaginga 85 (50.9)
     Computed tomographya 2 (1.2)
     Magnetic resonancea 2 (1.2)
    • ↵a One missing value.

    • View popup
    Table 3

    Neurologic status: changes in ASIA score from admission to discharge

    ASIA on Admission, n (%)ASIA on Discharge, n (%)Total
    ABCDE
    A1082300113 (44.8)
    B23383046 (18.3)
    C0075113 (5.2)
    D00015621 (8.3)
    E00005959 (23.4)
    Total110 (43.7)35 (13.9)18 (7.1)23 (9.1)66 (26.2)252 (100)
    • Abbreviation: ASIA, American Spinal Injury Association.

    • View popup
    Table 4

    Neurologic status: classification of ASIA score changes, n (%).

    Operative StatusWorsenedStableImproved
    Operative (n = 163)1 (0.6)137 (84.0)25 (15.3)
    Nonoperative (n = 89)1 (1.1)85 (95.5)3 (3.4)
    Total (n = 252)2 (0.8)222 (88.1)28 (11.1)
    • Abbreviation: ASIA, American Spinal Injury Association.

    • View popup
    Table 5

    Predictors of operative treatment.

    VariableUnivariable Logistic RegressionMultivariable Logistic Regressiona
    OR (95% CI) P OR (95% CI) P
    Age, continuous, y0.98 (0.96, 1.00)0.106 - -
    Age
     Young, <30 y (n = 91)Reference0.110--
     Old, ≥30 y (n = 166)0.64 (0.36, 1.09)---
    Sex
     Female (n = 42)Reference0.339--
     Male (n = 215)0.70 (0.33, 1.42)---
    Injury level
     Upper thoracic (n = 33)Reference-
     Lower thoracic (n = 122)1.22 (0.53, 2.69)0.634--
     Lumbar (n = 102)0.92 (0.40, 2.06)0.847--
    Insurance
     Private (n = 32)Reference0.633...
     Public (n = 225)0.82 (0.35, 1.78)-...
    Neurologic Examination
     Complete: ASIA A (ref) vs B–E; (n = 117)0.76 (0.45, 1.27)0.297......
     Incomplete: ASIA B–D (ref) vs A/E; (n = 81)0.45 (0.25, 0.81)0.009......
     Intact: ASIA A–D (ref) vs E; (n = 59)0.29 (0.16, 0.53)<0.0010.27 (0.13, 0.54)<0.001
    Time from injury to admission, continuous, d0.97 (0.94, 0.99)0.0480.95 (0.92, 0.99)0.007
    • Abbreviation: ASIA, American Spinal Injury Association.

    • ↵a Multivariable logistic regression analysis controlled for age, sex, and mechanism of injury.

    • View popup
    Table 6

    Predictors of neurologic improvement among all patients and operative patients. Multivariable logistic regression controlling for age, sex, admission neurologic exam, and level of injury.

    VariableUnivariable Logistic RegressionMultivariable Logistic Regression
    OR (95% CI) P OR (95% CI) P
    All patients, N = 193a
     Age0.432-
      Young, <30 y (n = 75)Reference---
      Old, ≥30 y (n = 118)0.71 (0.29, 163)---
     Sex0.820-
      Female (n = 25)Reference---
      Male (n = 168)0.88 (0.30, 3.19)---
     Injury level
      Upper thoracic (ref) vs lower thoracic/lumbar (n = 29)b 5.52 (1.10, 100)0.100--
      Lower thoracic (ref) vs upper thoracic/lumbar (n = 101)3.97 (1.67, 10.56)0.0020.61 (0.03, 3.96)0.656
      Lumbar (ref) vs thoracic (n = 63)0.14 (0.05, 0.33)<0.0010.14 (0.01, 0.83)0.071
     Insurance0.947-
      Private (n = 20)Reference---
      Public (n = 173)1.04 (0.23, 3.40)---
     Time from injury to admission
      Continuous, d0.93 (0.85, 0.99)0.0930.93 (0.84, 1.00)0.113
     Operative0.0340.067
      Nonoperative (n = 55)Reference-Reference-
      Operative (n = 138)3.83 (1.27, 16.61)-3.58 (1.02, 17.07)-
     Admission neurologic examination<0.0010.002
      Complete: ASIA A (n = 113)Reference-Reference-
      Incomplete: ASIA B–D (n = 80)8.71 (3.38, 27.05)-5.74 (1.94, 18.00)-
    Operative patients, N = 138
     Age0.299-
      Young, <30 y (n = 57)Reference---
      Old, ≥30 y (n = 81)1.63 (0.66, 4.27)---
     Sex0.921
      Female (n = 23)Reference---
      Male (n = 115)1.06 (0.35, 3.94)---
     Injury level
      Upper thoracic (ref) vs lower thoracic/lumbar (n = 20)4.85 (0.93, 89.30)0.133--
      Lower thoracic (ref) vs upper thoracic/lumbar (n = 71)3.36 (1.34, 9.22)0.0120.47 (0.02, 2.89)0.495
      Lumbar (ref) vs thoracic (n = 47)0.17 (0.06, 0.42)< 0.0010.09 (0.00, 0.51)0.027
     Time from admission to operating room
      Continuous, d1.01 (0.99, 1.03)0.237--
    • Abbreviation: ASIA, American Spinal Injury Association.

    • ↵a ASIA E patients were excluded, and none got worse in this cohort; only patients with a discharge ASIA score were included.

    • ↵b Excluded from the logistic regression model due to collinearity.

    • View popup
    Table 7

    Predictors of mortality among all patients (N = 257).

    VariableUnivariable Logistic Regression
    OR (95% CI) P
    Age
     Young, <30 y (n = 91)Reference0.940
     Old, ≥30 y (n = 166)1.10 (0.10, 23.81) -
    Sex
     Female (n = 42)Reference0.995
     Male (n = 215)1.20 (0.00, NA) -
    Injury level
     Upper thoracic (n = 33)Reference -
     Lower thoracic (n = 122)6.00 (0.00, NA)0.997
     Lumbar (n = 102)1.00 (0.00, 3.00)>0.999
    Insurance
     PublicReference0.996
     Private1.15 (0.00, NA) -
    Time from injury to admission
     Continuous, d0.90 (0.53, 1.07)0.517
    Operative status  
     Nonoperative (n = 90)Reference0.281
     Operative (n = 167)0.27 (0.01, 2.80) -
    Admission neurologic examination  
     Complete: ASIA B-E (n)Reference0.994
     Incomplete: ASIA A (n)6.11 (0.00, NA) -
    Length of stay, continuous, d0.99 (0.93, 1.02)0.806
    • Abbreviation: ASIA, American Spinal Injury Association.

    • Multivariable logistic regression analyses were not completed because no predictors met the threshold of p < 0.10 after univariable logistic regression analysis.

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Presentation, Management, and Outcomes of Thoracic, Thoracolumbar, and Lumbar Spine Trauma in East Africa: A Cohort Study
Chibuikem A. Ikwuegbuenyi, François Waterkeyn, Arthur Okembo, Costansia Bureta, Kassim O. Kassim, Hamisi K. Shabani, Scott Zuckerman, Roger Härtl
International Journal of Spine Surgery Apr 2024, 18 (2) 186-198; DOI: 10.14444/8575

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Presentation, Management, and Outcomes of Thoracic, Thoracolumbar, and Lumbar Spine Trauma in East Africa: A Cohort Study
Chibuikem A. Ikwuegbuenyi, François Waterkeyn, Arthur Okembo, Costansia Bureta, Kassim O. Kassim, Hamisi K. Shabani, Scott Zuckerman, Roger Härtl
International Journal of Spine Surgery Apr 2024, 18 (2) 186-198; DOI: 10.14444/8575
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